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Delivering Member Insight at the Point of Care

In health care, data has the power to help improve quality, reduce costs and make the experience of getting and paying for care easier for patients and their doctors and other providers.  

But critical information too often isn’t available to the right people when they need it. That means wasted time, wasted money and a lot of frustration. And worse, it could mean missed opportunities for better care.

A new agreement between Blue Cross and Blue Shield of Texas (BCBSTX) and technology company Epic begins to bridge the fragmentation that gets in the way.

Government agencies, technology companies and health care organizations have been working for at least a decade now to improve the electronic exchange of patient data.

Until recently, these efforts have focused almost exclusively on hospitals and doctors. This excludes a vast amount of information contained in health insurance claims, and it makes it harder for insurers and providers to actively collaborate to improve the health of member and patient populations.   

The agreement with Epic will give BCBSTX the ability to securely exchange comprehensive clinical and claims data with providers at the point of care using Epic’s electronic health record system, which is used by more than two-thirds of providers in the U.S.

“An option like this presents a beautiful way to bridge these silos that exist today across various settings of care,” says Krishna Ramachandran, vice president of provider performance at the Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas.

The new health information platform is scheduled to launch in late 2020 with a pilot group of BCBSTX's network providers. It will allow these doctors and hospitals to send real-time clinical information directly to the health plan. The plan, in turn, will be able to deliver claims data and insights directly into the EHR system.

"Delivering actionable insights at the point of care is incredibly powerful."

Most providers have comprehensive information on the care a patient has received within their own organization. They may also be able to see a patient’s history with other providers using the same EHR system, including via Epic’s Care Everywhere network. But the insurer may have a more comprehensive view from claims across many different providers and settings, including primary care, specialists, hospitals, imaging centers and labs.  

For example, analysis of claims data on the insurer’s side may expose a gap in care —a heart attack survivor who doesn’t appear to be getting cardiac rehabilitation or recommended drugs. That member’s doctor may get a notification in the EHR, allowing her to address the gap while the patient is in the office — or even proactively contact the patient to schedule a visit.

“Delivering actionable insights at the point of care is incredibly powerful,” Ramachandran says.

The claims data may also show if a service has already been performed by another provider, potentially reducing unnecessarily duplicated tests such as X-rays and MRIs — and reducing out-of-pocket costs for members.  

These insights may be particularly helpful to doctors and hospitals that participate in contracts with BCBSTX that include financial incentives for meeting cost and quality benchmarks for a population of patients — often referred to as value-based care. 

The claims data and insights will appear directly in the clinician’s regular workflow. “To them it just feels like the same system they’ve been using, but now there’s more information available,” says Ryan Bohochik, director of value-based care at Epic.

“That was a very big deal for the provider groups that we work with,” Bohochik says, noting that getting too many popups and having to navigate to different places is a common source of fatigue and frustration for clinicians.

Another benefit of the new platform is more mundane but also vital to making the health care system more efficient.

Most health plans report information to an independent accreditation organization and government programs to demonstrate that members are getting recommended care and quality health outcomes. This information is also collected under value-based contracts.

Sometimes, though, what appear as gaps in care are just gaps in records. “The clinical data that will flow from providers to the insurer via the new platform will reduce the time the insurer spends chasing charts for information that’s already in a member’s EHR,” Ramachandran says.  

When the platform goes live and the date begins flowing, more opportunities to improve collaboration and reduce administrative overhead exist.

It has the potential to make it faster for providers to confirm coverage for a course of treatment and support the claims they submit for payment. It may help them notify patients when their health plans offer benefits outside the scope of medical care, such as health coaching for people at risk of diabetes. 

“Now comes the real work and the real excitement,” Ramachandran says. “To bring some of these things to life to improve the lives of our members and our providers — that's where the real magic is.”

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association